The Coming Changes in Health Care:
What DCs Need to Know

Gerard W. Clum, DC, was the first president of Life Chiropractic College West, holding office from January 1981 through January 2011. Dr. Clum has served on the board of directors or as an officer of the Association of Chiropractic Colleges (ACC), the Council on Chiropractic Education (CCE), the International Chiropractors Association (ICA), the Foundation for Chiropractic Progress (F4CP), the Chiropractic Summit and the World Federation of Chiropractic (WFC).

He is now Presidential Liaison for External Affairs at Life University and director of The Octagon, a think-tank sponsored by Life University. In addition, he serves as a consultant and expert witness in matters related to chiropractic practice/care. He has been recognized as “Chiropractor of the Year” by ICA, “Man of the Year” by Dynamic Chiropractic and as one of the top five leaders of the chiropractic profession in a Dynamic Chiropractic readers’ poll. He has lectured throughout the world and has been recognized and honored for his efforts over the years by international, national, state and local groups. He can be reached at gerrycdc@aol.com.

In recent years, Dr. Clum has spoken to numerous employer, insurance and health industry groups on behalf of the Foundation for Chiropractic Progress, providing powerful, fact-based presentations on the positive effects chiropractic inclusion can bring to both new and traditional forms of health care delivery. He is among the most knowledgeable people in the profession on issues related to the Affordable Care Act and the potential for chiropractic participation in the new entities (Patient Centered Medical Homes and Accountable Care Organizations) being developed as part of health reform.

What recent trends and changes in the health care landscape are most likely to affect present and future chiropractors?

The most immediate changes that are underway involve the refinement of the rules and regulations associated with the implementation of the Affordable Care Act. The roles of Congress and the president are complete, to some degree. Once the legislation is passed and signed, it’s turned over to the Department of Health and Human Services (HHS) or other government agencies, to begin the process of implementing the legislation. And as we all know, sometimes things get implemented differently than they were conceived by the legislators who passed them.

Major Changes Begin in January 2014

The major components of the Affordable Care Act, which will change things on a broad scale in the United States, go into effect on January 1, 2014. So we’re in this ramp up, with several months to go, and it’s going to be fast and furious because there are many brand new structures that have never existed before. There’s no template for them so everything is being created out of whole cloth. It’s going to be bumpy and chaotic.

The first thing I would tell people, and I don’t want to offend anyone politically, is to not pay any attention to Fox News or MSNBC. Be careful where you get your information; get your information from trusted sources about what’s going on relative to health care reform. Check the website healthcare.gov. There is much to be learned from the Q&A on the site.

That being said, the next round of activity that’s going to be very important for the profession is that we’ve got 25 or 26 states out that have chosen not to implement the legislation.

In terms of choosing not to set up a state-based insurance exchange or marketplace?

Yes. At some point, somebody’s going to have to say what’s going to happen in those states. The conventional wisdom up to now has been that these states will have the federal options imposed upon them. That is, as a result of their inactivity they will default to the federal option. The curiosity is that it’s mainly Republican governors who are complaining about federal intervention, and by not setting up their own exchanges they are defaulting to greater federal intervention, with less control over their own domain. So it’s an odd situation. How those states sort out is going to be a very important issue along the way because that is going to determine what the essential benefits package is in those states. In the remaining states, the essential benefits package has been defined.

In some states it looks very good for chiropractic and in other states it doesn’t look very good at all in terms of the basic benefits package. California, for example, doesn’t look good at the moment. The plan [Kaiser Permanente] that has been used as the benchmark, as the basic benefits package guideline [that other plans must match or exceed], does not include chiropractic services.

Nondiscrimination and Essential Benefits

That would seem to be a clear violation of the nondiscrimination clause in the Affordable Care Act.

Absolutely. Section 2706 of the law, written by Senator Harkin, addresses nondiscrimination based on provider category or class. That provision is intended to specifically protect practitioners such as chiropractors. Now, there’s a version of this argument that you have to follow through to the end, which is that it’s based on services to be provided, rather than providers who provide services. So when we’re looking at it based on services to be provided, if there are services to be provided for whiplash injuries, for other musculoskeletal problems, for things that fall within the realm of the chiropractor, then they should be billable by a chiropractor under the system.

We, as chiropractors, want the protection to say that we are specifically included in the basic benefits package for A, B and C up to X, Y and Z. In some states, we’re going to get that. In a majority of states, we’re not. The question then is, if a chiropractor can legally and rightfully provide care in a given set of circumstances in that state, and those circumstances are covered under the provisions of the basic benefits package, then why can they not be covered if provided by a chiropractor? That interpretation is consistent with 2706.

So in the states that have chosen a benchmark plan for essential benefits that does not include chiropractors — and it’s a small number of states but California is by far the largest state — does it appear that there’s a longer battle brewing and that resolution of this issue may require action by a state insurance commissioner or legal action in the courts?

That’s true. There are lots of players that could be involved. The Secretary of HHS could get involved or the District Director of HHS could get involved. They could tell the state that under Section 2706, if a chiropractor is licensed to provide these services, then a chiropractor can provide them, period, and insurance companies need to pay them for it.

Shifting from Quantity to Quality

In the United States, there are now major efforts to gradually shift the main emphasis in health insurance reimbursement away from the traditional volume-based system (where the more services you deliver, the more you are paid) to one where reimbursement is based on quality outcomes. To understand this, it’s probably best to start by defining what health policy experts mean when they use the term “quality.” What’s your understanding of how quality is defined?

Quality is kind of a “handful of mercury” issue: it’s pretty tough to get hold of. But there are certainly measures. If we look at the hospital world, quality is measured by the frequency of readmissions after discharge for a given procedure, the number of hospital-acquired infections, the number of drug delivery errors during the period of confinement, and so on.

In our [chiropractic] world, they are likely to be more performance-oriented. They’re probably not going to be radically different from what we would do today. We’d look at an Oswestry, an SF-36 or an SF-12. Or we’d look at measures of quality of life or activities of daily living indices as a part of our care.

The idea that we can continue to see patients for X number of visits over Y period of time — without periodic evaluations that show progress in their functional improvement — is long gone. Probably the biggest change for chiropractors is that we need to start thinking about what we can do to demonstrate that between point A and point B, Mrs. Smith has improved. And the fact that I find greater joint mobility at her C6 and C7 is nice but it doesn’t answer the question.

Because that isn’t a patient-centered outcome?

Yes. What does Mrs. Jones think about how Mrs. Jones is doing? And what have you done to collect that information on a consistent, ongoing basis, other than asking, “Are you better today, Mrs. Jones?” So that kind of an approach is something that we’re going to have to standardize. We’re going to have to agree upon specifics. We’ve got low back indices, neck indices, indices for everything under the sun. Their use is going to have to become routine. This doesn’t have to be burdensome; they don’t have to be multi-page. They can be single page, where the patient fills it out in the waiting room and then it’s scored and popped into the record. And you make use of that as you go forward.

There are other aspects of quality — patient satisfaction with the outcomes of their care, your delivery of the care, the environment in which the care is delivered. All of those will become metrics that will become part of this discussion over time. But really, one of the biggest changes that is coming about in the Affordable Care Act in terms of funding, particularly in the Patient Centered Medical Home model or the Accountable Care Organization model, is the idea that there will be additional payment made when practitioners of all kinds, including chiropractors, do things to reduce the level of care needed and save the system money.

In the past, as you said at the beginning of this question, the only ways you made money in healthcare were that you provided more, or more expensive, services. And that was true for everybody across healthcare. They provided more care for more money; that’s how it worked. It is now understood that the system cannot continue to expand exponentially on that basis; that we’ve got to change the incentives so that practitioners behave differently. So now practitioners will be compensated for providing care that produces a quicker and better result, rather than simply more, or more expensive care as in the past.

This is a sea-change, a truly massive shift. We haven’t seen this before.

The two mechanisms that you mentioned, the Patient Centered Medical Homes (or healthcare homes) and the Accountable Care Organizations, are essentially team-based healthcare delivery arrangements. Under the Affordable Care Act, these can include chiropractors but are not required to do so. What else should DCs know about these groups and about possibly seeking to participate in them?

First and foremost, they need to know they exist. I don’t say that jokingly, I say it very sincerely. I think there are a great many chiropractors across the country (as there are a great many medical doctors) who have heard these terms but haven’t got a clue as to what they mean. So the first thing I would do is start Googling “accountable care organizations” and I’d spend half an hour wandering through websites and reading until you get a sense of what they are.

Basically, they are vertically integrated environments that take a patient from a primary care environment to an end-of-life environment, and include everything in between. They seek to integrate across that spectrum of care, to coordinate on a team basis the activities of the providers involved, for the greatest good. You know as well as I do that today, any patient can walk into 20 different providers, get 20 different prescriptions for oxycodone, and take themselves out by the end of the day if they want, by taking the drugs. There’s no integration in the system. A person can go out and doctor shop and get healthcare as many times as they want in a given day.

Well, this new system is intended to try to stop that, to stop the abuses but also to refine and improve the normal or intended use of care. It is very much team-oriented and it’s very much oriented to allowing people to practice at the top of their license.

What does it mean to practice at the top of your license?

Surgeons drawing blood and taking blood pressure is a waste of time and money. Same goes for a chiropractor rubbing an ultrasound or ice on somebody; it’s a waste of their skill. You want to work at the highest level of your skill. As a chiropractor, I think that’s evaluating and adjusting patients as needed. If you want or need something else to be done in your office, let someone else do it. And let that person work to the level of his or her training and greatest skill.

In a vertically integrated system there might be 20 practitioners that could tend to a particular low back case — a neurologist, an orthopedist, a physical therapist, a chiropractor, a massage therapist, an acupuncturist, a rheumatologist, etc.

Efficient Entry into the System

But the question is what’s in the patient’s best interest?

What’s the point at which to begin? The system would be designed to facilitate the most efficient entry into it. What percentage of these patients can we address with the greatest success, at the least cost, with the greatest amount of patient satisfaction, in the shortest period of time? Now if this model causes the group, the entity — the PCMH or the ACO — to make more money by doing less, what we will see is that for the first time, there’s an incentive to make more money by not doing more. Sea-change is the only word for it. That’s really the big thing.

So let’s get back to where we began this question, with the ACO and PCMH products. Kaiser Permanente is a classic ACO. A PCMH is a building block of an HMO [health maintenance organization]. It’s a group that agrees to work together to take care of a given number of patients. They refer to the hospital within the ACO; those types of involvements are coordinated. Again, records are integrated, tests aren’t repeated unnecessarily, imaging isn’t done repeatedly because they didn’t get the x-ray from one office to the other. All those kinds of things, because they are handled electronically, become integrated and more efficient.

This is a free market arrangement. Chiropractors can function any place they can inject themselves into the system. In this scenario, it is crucial that chiropractors understand the literature regarding cost-effectiveness and patient satisfaction associated with the care that we deliver.

You’ve given a number of presentations over the past few years to employer, insurance and health industry groups on behalf of the Foundation for Chiropractic Progress. One of these was at the Accountable Care Organizations (ACO) Summit in Texas early in 2013. What are you telling these groups and how have people at these conferences responded?

The first thing we’re telling them is that everyone in healthcare is paying all sorts of attention to heart disease, obesity and diabetes. But the number one cause of disability worldwide in 2012 was low back pain. The number two reason that a person visits a healthcare provider in the United States is a musculoskeletal complaint.

This observation is what I call low hanging fruit. I explain that while they’re off dealing with the activity and situations that TV shows are about, the real basics of human endeavor are going unattended or poorly attended. Then I give them key research articles. Last year there was a study [1] from the Washington State Department of Labor and Industry that found that on a risk-adjusted basis, if a person sees a surgeon first, they are 28.5 times more likely to have surgery than if they see a chiropractor first. If you’re running a hospital that’s trying to contain costs, and you know what those numbers are, your ears perk up big-time at these findings. When somebody explains the magnitude of this problem, and gives low-cost, low-tech, high-touch interventions to replace what is currently being done, showing evidence of money being saved individually and globally, from radiography to MRI to surgery to hospitalization, then as the hospital administrator you want to make changes!

I would underscore that the 28.5 to 1 ratio you cited regarding the greater likelihood of having surgery if you go first to a surgeon rather than a chiropractor, was the difference after the severity of the condition had been accounted for.

Yes, this was apples to apples, oranges to oranges.

It’s a remarkably powerful point for chiropractors to make.

There was also a 2010 study out of Tennessee [2] that looked at low back pain patients. They provided data on a non-risk adjusted basis as well as on a risk-adjusted basis. In that study, the chiropractic care produced a 40% savings if risk was not accounted for. But it also produced a 20% savings on a risk-adjusted basis.

How to Present the Best Case for Inclusion in a PCMH or ACO

So for an individual chiropractor, who is in private practice on their own or with a chiropractic group, or for a student who is about to graduate, am I hearing you correctly that you’re saying these DCs need to know these facts well, if they’re trying to make the case that they should be considered for inclusion in a patient-centered medical home or accountable care organization that’s forming in their area? That having this information is critical?

No question. You can’t even begin the conversation without it.

Are there any other comparable studies, or talking points, that you would recommend that our doctors of chiropractic have at their fingertips?

Yes. In the insurance world, chiropractic is seen as a cost center. But it’s not actually a cost center, it’s a savings center. All of these data show this to be true. We need to begin discussing the cost-replacement value. We don’t add cost to the system; we take expense out of it.

And this is because if people don’t go to a chiropractor, they’ll go to a more costly, less cost-effective practitioner for the same condition?

Yes, exactly. This fact involves a huge shift in thinking for folks in the insurance world because they don’t see chiropractors in that light. It’s very important that we keep bringing this concept of expense reduction to the attention of people in the insurance and policy worlds. That’s number one.

Number two, there’s probably no hotter issue today in all healthcare than prescription drug abuse. It must be understood by all that the chiropractor not only gets the patient back to an improved more functional state sooner and at less cost, but without the drugs and the secondary issues of abuse, dependency and addiction.

Think of it from the ACO’s perspective: a patient with a hot low back starts down Oxycontin Road and he’s a liability to the ACO over time. We know the chiropractor can help that patient reduce his drug use profile, a significant contribution that the chiropractor can offer through his or her participation in the ACO or PCMH. Thus, including chiropractors in ACOs or PCMHs will save them money; it will help their bottom line.

So my advice to chiropractors approaching an ACO or PCMH about participation is to commit to memory the data on prescription drug abuse — Vicodin and Oxycontin — to rattle that off, along with the average costs of surgery and the studies showing that chiropractic care makes many surgeries unnecessary.

You’ve got to know all of those things, because this is “follow the money.” You need to demonstrate where they’re spending money and how we can give them a safer, more cost-effective, minimally iatrogenic intervention in place of it down the road. That’s the issue; that’s the picture we’ve got to paint. Now, they’re not going to believe us just because we say it. But they’ll start thinking about it. We have to make the “What if?” strong enough.

I don’t know if you happened to catch the testimony before Senator Sanders’ recent hearing on some veterans’ bills that he’s put forward, including an expansion of chiropractic services.

I’m aware of the bills. What can you tell us about the testimony at the hearing?

If you go to that hearing, at the one-hour-and-nine-minute mark, you can pick up the discussion about chiropractic services. There’s a fellow that represents the Vietnam Veterans of America. He’s saying that Congress set this in place ten years ago, yet the military are still screwing around with it when veterans need and want chiropractic coverage.

Then Wayne Jonas, the President of the Samueli Institute and former Director of the National Center for Complementary and Alternative Medicine at NIH, gets up and talks about how the veteran of today, the injured warrior of today, needs chiropractic care. He made very strong statements about it, not equivocal at all.

Dr. Jonas was also a military medical doctor for over 20 years. He knows what he speaks of.

Yes. Those kinds of discussions are available online for free. I’d encourage folks to send this type of info as an email attachment as these conversations begin. We’ve got to make our case, pure and simple.

Daniel Redwood, DC, the interviewer, is a Professor at Cleveland Chiropractic College–Kansas City. He is the Editor-in-Chief of Health Insights Today, Associate Editor of Topics in Integrative Healthcare and serves on the editorial board of the Journal of the American Chiropractic Association. Dr. Redwood’s website and health policy blog are at www.redwoodhealthspeak.com.

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